A literature review of quality in lower gastrointestinal endoscopy from the patient perspective

The impact on clinical outcomes and healthcare resources from discontinuing colonoscopy surveillance subsequent to low-risk adenoma removal: A simulation study using the OncoSim-Colorectal model

OBJECTIVE

To estimate the impact on clinical outcomes and healthcare resource use from recommending that patients with 1-2 low-risk adenomas (LRAs) return to routine fecal immunochemical test (FIT) screening instead of surveillance colonoscopy, from a Canadian provincial healthcare system perspective.

METHODS

The OncoSim-Colorectal microsimulation model simulated average-risk individuals eligible for FIT-based colorectal cancer (CRC) screening in Alberta, Canada. We simulated two surveillance strategies that applied to individuals with 1-2 LRAs (<10 mm) removed as part of the average risk CRC screening program: (a) Surveillance colonoscopy (status quo) and (b) return to FIT screening (new strategy); both at 5 years after polypectomy. A 75 ng/mL FIT positivity threshold was used in the base case. The simulations projected average annual CRC outcomes and healthcare resource use from 2023 to 2042. We conducted alternative scenarios and sensitivity analyses on key variables.

RESULTS

Returning to FIT screening (versus surveillance colonoscopy) after polypectomy was projected to have minimal impact on long-term CRC incidence and deaths (not statistically significant). There was a projected decrease of one (4%) major bleeding event and seven (5%) perforation events per year. There was a projected increase of 4800 (1.5%) FIT screens, decrease of 3900 (5.1%) colonoscopies, and a decrease of $3.4 million (1.2%) in total healthcare costs per year, on average. The annual colonoscopies averted and healthcare cost savings increased over time. Results were similar in the alternative scenarios and sensitivity analyses.

CONCLUSIONS

Returning to FIT screening would have similar clinical outcomes as surveillance colonoscopy but could reduce colonoscopy demand and healthcare costs.

Novel classification for adverse events in GI endoscopy: the AGREE classification

BACKGROUND AND AIMS

Standardized registration and evaluation of adverse events (AEs) are essential to assess the safety of endoscopic procedures. We propose a novel classification system, named adverse events in GI endoscopy (AGREE), adapted from a widely accepted surgical tool.

METHODS

The Clavien-Dindo classification for surgical AEs was adapted for endoscopy. To validate the novel classification, we assessed if the severity of AEs, as perceived by 10 endoscopists, 10 endoscopy nurses, and 10 patients, corresponded with the severity grading used in the AGREE classification in 10 pairwise comparisons. We additionally assessed the correlation between the AGREE classification and the American Society for Gastrointestinal Endoscopy (ASGE) classification. The acceptability of the AGREE classification was evaluated through an international questionnaire.

RESULTS

The perception of endoscopists, endoscopy nurses, and patients corresponded with the severity grading of the AGREE classification in 80% of cases (238/299). The AGREE classification significantly correlated with the ASGE classification (ρ = .760). Fifty-seven of 84 experts (68%) completed a questionnaire regarding the acceptability of the AGREE classification. The experts consulted considered the AGREE classification as simple (86%), reproducible (98%), logical (98%), and useful (96%). Most case presentations (84%) were correctly graded according to the AGREE classification.

CONCLUSIONS

The AGREE classification provides a standardized and reproducible approach to the assessment of AEs in diagnostic and therapeutic GI endoscopy. Broad implementation of the AGREE classification may facilitate the evaluation of AEs across different endoscopists, disciplines, endoscopy services, and regions. This standardization of AE reporting will support improved quality assurance in GI endoscopy.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented, and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high-quality procedures. These were subcategorized into three subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators), and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, "rate of adequate bowel preparation," was set at ≥80%.

DISCUSSION

It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.

Assessment of Patient Satisfaction in Digestive Endoscopy: A Narrative Review of the Literature

Endoscopic examinations are often perceived as invasive, annoying, and painful procedures. For this reason, it is essential to know the patient's opinion to improve service quality and adherence to screening programs. The European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) recommend the identification of quality indicators, including patient satisfaction. The aim of this narrative review of the literature is to investigate the tools available to evaluate customer satisfaction in digestive endoscopy, highlighting which sections and items should be present in a questionnaire for complete evaluation. A narrative review of the literature was performed through five biomedical databases. A total of 125 studies were selected. The review process resulted in a total of 12 scientific papers meeting the inclusion criteria. This review suggests which items and sections should be present in a questionnaire that evaluates customer satisfaction in digestive endoscopy. Customer satisfaction verification programs in the normal routine of a digestive endoscopy service are essential to allow continuous improvement of the offered services.

A pilot study of virtual reality as an alternative to pharmacological sedation during colonoscopy

Background and study aims  Conscious sedation is routinely administered for colonoscopy but is associated with risks and inconveniences. We sought to determine whether virtual reality (VR) may be a feasible alternative. Patients and methods  Twenty-seven individuals scheduled for screening/surveillance colonoscopy participated. The VR device was activated throughout the colonoscopy, but subjects could opt out and request standard medications. Questionnaires were administered, and variables were assessed on a scale of 1 to 10. Results  Cecal intubation was achieved in all cases without adverse events (AEs). Study colonoscopies were completed without pharmacological rescue in 26 of 27 patients (96.3 %) and procedure times were comparable to baseline. Subjects reported minimal pain, high satisfaction, and willingness to use VR for future colonoscopies to avoid narcotics and resume normal activities including driving. Conclusion  Replacing pharmacological sedation with VR did not impact colonoscopy completion rates, procedure time, or AEs. Satisfaction was high and only one subject (3.7 %) chose to suspend VR. VR can be an effective alternative for patients undergoing colonoscopy who prefer to avoid narcotics.

Patient participation in gastrointestinal endoscopy - From patients' perspectives

Background

Patient participation is associated with satisfaction and improved health‐related outcomes. In gastrointestinal endoscopy, patient participation is an underexplored area.

Objective

To gain understanding on patients' experiences, attitudes and preferences concerning patient participation in the endoscopy pathway.

Methods

Semi‐structured interviews with endoscopy patients (n = 17, female n = 8, male n = 9, ages 19‐80 years) were performed. Interview transcripts were analysed using qualitative content analysis. Participants were recruited by purposive sampling from an endoscopy unit in a Swedish university hospital. Inclusion:≥ 18 years, fluency in Swedish and recent experience of endoscopy at the unit.

Results

Five generic categories emerged, two within the area of the patient's role, which was described as active or passive/included or excluded. Another three generic categories related to factors, critical to active participation, including organizational aspects, impressions of staff and individual circumstances were identified. In this context, patient participation described in the interviews was on a low to basic level, although sometimes reaching a higher level when staff ‘invited’ patients in decision making.

Discussion

This study contributes to the understanding of patient participation in endoscopy. Patients are in an inferior position and need support from the staff for an active role in their care. Although there were variations on the perceived importance of different factors, a heavy responsibility lies on the endoscopy staff to acknowledge the patients' individual needs and to facilitate patient participation.

Conclusions

Endoscopy staff has a key role in supporting patient participation. In endoscopy settings, patient participation is vulnerable to multiple factors.

Procedural Anxiety, Pain Catastrophizing, and Procedure-Related Pain during EGD and Colonoscopy

OBJECTIVES

Although sedatives and analgesic drugs defuse anxiety and relieve pain, digestive endoscopy still is uncomfortable and painful for some patients. Identifying patients who tolerate digestive endoscopy less well remains difficult. The present study evaluated the relations between procedural anxiety, catastrophizing thoughts, and pain, using a prospective design and multimodal assessments of pain.

METHODS

A total of 118 consecutive patients were assessed for procedural anxiety before endoscopy. During endoscopy, a doctor rated the patients' pain behavior. Before discharge, the patients retrospectively rated endoscopy pain and related catastrophizing thoughts.

RESULTS

Notwithstanding sedation, our study revealed large between-subject variability in pain. Catastrophizing thoughts mediated the relation between procedure-related pain observed by the doctor and pain intensity reported by the patient. Catastrophizing thoughts also mediated the effect of procedural anxiety. Our study showed that anxiety exacerbates endoscopy pain when the patient engages in ruminative thinking and feels unable to cope with unpleasant bodily sensations.

CONCLUSIONS

This study shows that catastrophizing thoughts account for between-subject differences in endoscopy pain. Rumination and helplessness but not magnification explain how procedural anxiety may evolve in a painful endoscopy experience. To the extent that one can address catastrophizing thoughts, endoscopy pain can be mitigated, especially for patients who are difficult to sedate.

Undergoing repeated colonoscopies - experiences from patients with inflammatory bowel disease

Background: Patients with Inflammatory Bowel Disease (IBD) undergo repeated colonoscopies to monitor their lifelong disease.Objective: To describe experiences from repeated colonoscopies in patients with IBD.Methods: Within a qualitative design 33 patients with IBD who had undergone at least three colonoscopies were interviewed by telephone. Hermeneutic interpretation served as the framework of the analysis.Results: The colonoscopy procedure was explained as strenuous to undergo and interfered with daily life. It reminded patients of a lifelong disease, but the necessity of the colonoscopy, being life-saving, was highlighted. The colonoscopies entailed several unpredictable aspects - no control over pain, potential blame and unpredictable care. Shame, inferiority and uncertainty enhanced the feeling of being exposed and vulnerable.Conclusion: Repeated colonoscopies can be perceived as both an assurance of life and a reminder of a lifelong illness. Healthcare professionals need to provide support in terms of awareness of patients' vulnerability, despite extensive experience of the colonoscopy procedure. For example, person-centred care and continuity in care are potential interventions based on the results of this study. Another important aspect of care is to minimise interference in everyday life to prevent feelings of loss of the healthy self, for example by self-administrated outpatient booking systems.Summarize the established knowledge on this subject. • Previous research in quality related to colonoscopy has mainly focused on technical and medical aspects. • Knowledge based on the patients' perspective is rare and the few existing studies included mainly persons included in screening programs.What are the significant and/or new findings of this study? • Patients with IBD undergoing repeated colonoscopies express specific needs in several aspects related to the colonoscopy procedure: • Continuity and a person-centered approach from healthcare professionals. • Support to cope with feelings of shame and inferiority as well as pain.

Patient Experiences with Colonoscopy: A Qualitative Study

Background

Patient perspectives have important roles in improving the quality of colonoscopy services. The purpose of this qualitative study was to obtain the perspectives of patients who recently had undergone colonoscopy procedures, about their experiences with bowel preparation, the procedure itself, and communication of follow-up results and recommendations.

Methods

We recruited adults who had undergone a colonoscopy, to participate in semistructured interviews. Interviews were audiotaped, transcribed and analyzed using inductive qualitative methods.

Results

Twenty-four adults (58% female) with an average age of 53.8 years participated. Results were categorized within the themes of bowel preparation, the colonoscopy procedure and communication of the results. Participants appreciated having clear consistent plain language messages about bowel preparation. Some participants experienced additional challenges to understanding, and navigating, colonoscopy procedures. At the time of the procedure, positive and reassuring interactions with, and between, members of the health care team, in addition to management of physical pain and discomfort, were important. Participants wanted clear and timely information about the results of their test.

Conclusions

Understanding patients' needs for information and support can promote higher quality colonoscopy services. Our findings suggest that quality indicators should include: patients' perspectives of the clarity of bowel instructions; the need for supports that are not routinely provided; the extent to which concerns about the procedure are addressed; interactions with the endoscopy team; the endoscopy team's interactions with each other; comfort during the procedure, and the timeliness and clarity of results and follow-up instructions. These indicators should be included in annual patient surveys.

Hospital Design with Nature Films Reduces Stress-Related Variables in Patients Undergoing Colonoscopy

PURPOSE

To examine whether patients' experiences could be improved during colonoscopy by designing the examination room to include a digital screen showing calm nature films.

BACKGROUND

Colonoscopy is the gold standard for examination of the large intestine and the rectum. Around 50% of individuals invited for colorectal cancer screening choose to refrain from the screening due to fear and anxiety. It is therefore important to improve patients' comfort during the procedure.

METHOD

One of the four endoscopy rooms was rebuilt to include a large digital screen showing calm nature films. Patients were randomized to intervention (i.e., the room showing films) or control. During the colonoscopy, pulse and oxygen saturation were measured and the patients graded the intensity of pain and anxiety. Blood samples were taken regularly during the examination and were analyzed for glucose, cortisol, and prolactin.

RESULTS

The presence of calm nature films during colonoscopy decreased the release of cortisol, increased prolactin levels, and enhanced oxygen saturation. These effects were more apparent in patients who were unfamiliar with the procedure and the environment, patients who underwent the examination without analgesics or sedation, and patients whose examination procedure was relatively difficult and took a long time.

CONCLUSIONS

The intervention described in this study is easy to implement and might help improve the patient experience during colonoscopy. However, this study was performed in a single health institution, and more studies are needed to further explore the role of film interventions in endoscopic and other medical procedures.

The Colonoscopy Satisfaction and Safety Questionnaire (CSSQP) for Colorectal Cancer Screening: A Development and Validation Study

Colonoscopy services working in colorectal cancer screening programs must perform periodic controls to improve the quality based on patients' experiences. However, there are no validated instruments in this setting that include the two core dimensions for optimal care: satisfaction and safety. The aim of this study was to design and validate a specific questionnaire for patients undergoing screening colonoscopy after a positive fecal occult blood test, the Colonoscopy Satisfaction and Safety Questionnaire based on patients' experience (CSSQP). The design included a review of available evidence and used focus groups to identify the relevant dimensions to produce the instrument (content validity). Face validity was analyzed involving 15 patients. Reliability and construct and empirical validity were calculated. Validation involved patients from the colorectal cancer screening program at two referral hospitals in Spain. The CSSQP version 1 consisted of 15 items. The principal components analysis of the satisfaction items isolated three factors with saturation of elements above 0.52 and with high internal consistency and split-half readability: Information, Care, and Service and Facilities features. The analysis of the safety items isolated two factors with element saturations above 0.58: Information Gaps and Safety Incidents. The CSSQP is a new valid and reliable tool for measuring patient' experiences, including satisfaction and safety perception, after a colorectal cancer screening colonoscopy.

Process improvement for a complex dual medical procedure

Pancreatic extracorporeal shock wave lithotripsy followed by endoscopic retrograde cholangiopancreatography is accepted worldwide as a treatment for a large, symptomatic, obstructing pancreatic stones. However, timely completion of the combined process requires coordination of equipment and personnel from two different complex procedures.

We used Lean management tools in a week-long event to redesign the process around the patient. Using idea-generated Plan Do Study Act cycles to refine the process, from scheduling to postprocedure recovery, equipment and personnel were aligned to allow these two procedures to occur in immediate succession.

The redesigned process resulted in all patients receiving both procedures without delay. This eliminated over 8 hours of wait time. Standard work and a newly created complex scheduler improved flow. We reduced the number of anaesthetics for patients without prolonging the procedure length.

Results From a Patient Experience Study in Pediatric Gastrointestinal Endoscopy

OBJECTIVE

Gastrointestinal endoscopy in children has become a standard diagnostic and therapeutic modality. The aim of our study was to characterize the most memorable elements of the patient experience from the parent's and patient's perspective and determine ways to improve the overall quality of their experience.

METHODS

Using a structured questionnaire, we conducted 47 phone interviews with families who had recently undergone gastrointestinal endoscopic procedures.

RESULTS

Our study showed clear communication and mutual agreement on care decisions contributed to positive experiences. Inadequate communication of information regarding alternatives to the procedure and risk of complications during the informed consent discussion contributed to negative patient experiences. Standardization of postprocedure follow-up and timely communication of pathology findings also had potential for improvement.

CONCLUSION

Our study revealed 2 areas for quality improvement interventions: The need to ensure that alternatives and complications are thoroughly discussed and the need for standardization of postprocedure follow-up.

A randomized controlled trial comparing continuous and as-required nitrous oxide use during screening colonoscopy

BACKGROUND AND STUDY AIMS

Entonox is a 50 : 50 combination of nitrous oxide and oxygen, which may be used to manage pain during colonoscopy. The optimal mode of Entonox administration is unknown. The aim of this study was therefore to compare continuous and as-required Entonox use.

PATIENTS AND METHODS

Patients attending for screening colonoscopy at a single centre were randomized to continuous or as-required Entonox use. The primary outcome measure was the patient's overall pain rating at the time of discharge (verbally administered numerical ratings scale, 0=no pain and 10=extreme pain). Secondary outcome measures included the patients' experience of pain during the colonoscopy (rated every 2 min), side effects and the need for rescue intravenous medications.

RESULTS

A total of 108 patients were randomized, and 100 completed the study (46 continuous, 54 as required). The overall pain scores at discharge did not differ between those who used Entonox continuously and as required (mean=2.4 vs. 3.2, P=0.08). There were also no differences in the experience of pain during colonoscopy (mean=1.8 vs. 2.2, P=0.28; peak=4.2 vs. 4.8, P=0.26; and area under curve=23 vs. 30, P=0.24). Patients with high anxiety had greater overall pain scores (mean=3.7 vs. 2.4, P=0.03). Light headedness occurred more often with continuous Entonox use (48 vs. 21%, P=0.009).

CONCLUSION

Among patients attending for screening colonoscopy, comfort ratings were similar in those using Entonox continuously and as required, but light headedness was more common with continuous use (NCT identifier: 01865721).

Abdominal pain, diarrhea, constipation--which symptom is more indispensable to have a colonoscopy?

BACKGROUND

Doctors perform colonoscopies when presented with various symptoms, including unexplained weight loss, rectal bleeding, changes in bowel habits, however many other symptoms such as abdominal pain, diarrhea and constipation may be more popular in outpatient department. As a result, we want to evaluate the three symptoms which is more need to have a colonoscopy. Abdominal pain, diarrhea and constipation are the main reasons for patients to visit the outpatient department of gastroenterology. And the colonoscopy is regularly recommended for outpatients with the above symptoms in China. The aim of this study was to evaluate the value of colonoscopy on the diagnosis of each single symptom of the three above and answer the question of my title-which symptom is more indispensable to have a colonoscopy?

METHODS

Colonoscopic findings of 580 outpatients with a single of these three common lower gastrointestinal symptoms were systematically analyzed in retrospect.

RESULTS

In this study, no significant difference was found in the positive rate of colon polyps, cancer and ulcerative colitis among these three groups divided by symptoms. The incidence of colon polyps, cancer and colitis for the chronic abdominal pain, chronic diarrhea and constipation group are 20.8%, 57.1%, 42.9% respectively. The incidence of colon polyps and cancer increases with age. Among the age groups 13-39 years old, 40-59 years and > 60 years, the incidence is 7.9%, 13.6%, 22.4% respectively. There is no significant difference in the incidence of colon polyps and colon cancer in our groups of symptoms.

CONCLUSION

The results show the prevailing opinion that the indications of colonoscopy just refer to symptom and physical sign nowadays in China is inappropriate and it is best to take a full consideration of patient's age, auxiliary examinations, family diseases history and other factors.

Rates of minor adverse events and health resource utilization postcolonoscopy

BACKGROUND

Little is known about minor adverse events (MAEs) following outpatient colonoscopies and associated health care resource utilization.

OBJECTIVE

To estimate the rates of incident MAE at two, 14 and 30 days postcolonoscopy, and associated health care resource utilization. A secondary aim was to identify factors associated with cumulative 30-day MAE incidence.

METHODS

A longitudinal cohort study was conducted among individuals undergoing an outpatient colonoscopy at the Montreal General Hospital (Montreal, Quebec). Before colonoscopy, consecutive individuals were enrolled and interviewed to obtain data regarding age, sex, comorbidities, use of antiplatelets/anticoagulants and previous symptoms. Endoscopy reports were reviewed for intracolonoscopy procedures (biopsy, polypectomy). Telephone or Internet follow-up was used to obtain data regarding MAEs (abdominal pain, bloating, diarrhea, constipation, nausea, vomiting, blood in the stools, rectal or anal pain, headaches, other) and health resource use (visits to emergency department, primary care doctor, gastroenterologist; consults with nurse, pharmacist or telephone hotline). Rates of incident MAEs and health resources utilization were estimated using Bayesian hierarchical modelling to account for patient clustering within physician practices.

RESULTS

Of the 705 individuals approached, 420 (59.6%) were enrolled. Incident MAE rates at the two-, 14- and 30-day follow-ups were 17.3% (95% credible interval [CrI] 8.1% to 30%), 10.5% (95% CrI 2.9% to 23.7%) and 3.2% (95% CrI 0.01% to 19.8%), respectively. The 30-day rate of health resources utilization was 1.7%, with 0.95% of participants seeking the services of a physician. No predictors of the cumulative 30-day incidence of MAEs were identified.

DISCUSSION

The incidence of MAEs was highest in the 48 h following colonoscopy and uncommon after two weeks, supporting the Canadian Association of Gastroenterology's recommendation for assessment of late complications at 14 days. Predictors of new onset of MAEs were not identified, but wide CrIs did not rule out possible associations. Although <1% of participants reported consulting a physician for MAEs, this figure may represent a substantial number of visits given the increasing number of colonoscopies performed annually.

CONCLUSION

Postcolonoscopy MAEs are common, occur mainly in the first two weeks postcolonoscopy and result in little use of health resources.

Magnetic endoscopic imaging during colonoscopy is associated with less pain and decreased need of analgesia and sedation--results from a randomized controlled trial

OBJECTIVE

Colonoscopy is the method of choice for examining patients with lower gastrointestinal symptoms. The procedure is, however, in many cases, associated with pain and impaired compliance. Magnetic endoscopic imaging (MEI) generates a three-dimensional image of the colonoscope on a computer screen which may enable the colonoscopist to avoid looping, and consequently improve patient satisfaction.

MATERIAL AND METHODS

In this randomized controlled trial, 200 outpatients referred to colonoscopy at Østfold Hospital Trust, Fredrikstad, Norway, were included. Patients were randomized to either the standard arm (using fluoroscopy on demand, n = 100), or the MEI arm (n = 100). End points were time to cecum, subjective pain experiences, and use of sedation or analgesics.

RESULTS

Out of a total of 200 patients, 54% were men. However, no significant differences between the groups according to gender were found. Fluoroscopy was applied in 23% of the cases in the standard group. Use of MEI was associated with decreased time to cecum (p < 0.05), decreased pain scores (Visual Analogue Scale, p < 0.05), decreased need of analgesia (p < 0.01), and decreased amount of administered midazolam and pethidin (p < 0.05 in both).

CONCLUSIONS

MEI during colonoscopy was associated with decreased pain and less on-demand requests for sedation and analgesia. In addition, the use of MEI reduced the cecal intubation time. Consequently the implementation of magnetic endoscopic imaging in the endoscopy suits may be beneficial, particularly in the clinically difficult cases.

Development and validation of a nurse-assessed patient comfort score for colonoscopy

BACKGROUND

Comfort during colonoscopy is a critical component of safety and quality.

OBJECTIVE

To develop and validate the Nurse-Assessed Patient Comfort Score (NAPCOMS).

DESIGN

Prospective scale validation.

SETTING

Colorectal cancer screening centers in the United Kingdom and Canada.

PATIENTS

A total of 300 consecutive patients undergoing colonoscopy at participating colorectal cancer screening centers.

INTERVENTION

The NAPCOMS was developed by using a modified Delphi process. During colonoscopy, two endoscopy room nurses independently observed and rated patient comfort and tolerability by using NAPCOMS. In addition, endoscopists reported global comfort scores and patients' reported global comfort by using visual 4-point Likert and National Health Service-United Kingdom Global Rating Scales.

MAIN OUTCOME MEASUREMENTS

Reliability and validity of NAPCOMS was measured by using intraclass correlations (ICC) between nurse ratings of colonoscopies and between NAPCOMS, endoscopist ratings, and patient ratings of global comfort.

RESULTS

The ICC for the overall NAPCOMS was 0.84 (95% confidence interval [CI], 0.80-0.87). There was high agreement between the NAPCOMS and endoscopist ratings of comfort (ICC = 0.77; 95% CI, 0.72-0.81), moderate agreement between the NAPCOMS and patient ratings (ICC = 0.61; 95% CI, 0.53-0.67), and moderate agreement between the endoscopist and patient ratings (ICC = 0.52; 95% CI, 0.43-0.60).

LIMITATIONS

NAPCOMS was validated in outpatients who received colonoscopy with minimal to moderate sedation as part of a screening and surveillance program, so performance among inpatients or those requiring deep sedation was not tested.

CONCLUSION

NAPCOMS is a reliable and valid tool for assessing patient comfort in the setting of outpatient colonoscopy performed with minimal to moderate sedation.

The endoscopy Global Rating Scale-Canada: development and implementation of a quality improvement tool

BACKGROUND

Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality highlight the need for endoscopy facilities to review the quality of the service they offer.

OBJECTIVE

To adapt the United Kingdom Global Rating Scale (UK-GRS) to develop a web-based and patient-centred tool to assess and improve the quality of endoscopy services provided.

METHODS

Based on feedback from 22 sites across Canada that completed the UK endoscopy GRS, and integrating results of the Canadian consensus on safety and quality indicators in endoscopy and other Canadian consensus reports, a working group of endoscopists experienced with the GRS developed the GRS-Canada (GRS-C).

RESULTS

The GRS-C mirrors the two dimensions (clinical quality and quality of the patient experience) and 12 patient-centred items of the UK-GRS, but was modified to apply to Canadian health care infrastructure, language and current practice. Each item is assessed by a yes⁄no response to eight to 12 statements that are divided into levels graded D (basic) through A (advanced). A core team consisting of a booking clerk, charge nurse and the physician responsible for the unit is recommended to complete the GRS-C twice yearly.

CONCLUSION

The GRS-C is intended to improve endoscopic services in Canada by providing endoscopy units with a straightforward process to review the quality of the service they provide.

Use of alternative therapies in patients submitted to anorectal manometry

BACKGROUND AND AIM

Anorectal manometry is used in the evaluation of disorders of the lower gastrointestinal tract: constipation, incontinence, anorectal pain. Most of these conditions are invalidating. Moreover, the patients do not benefit from a perfect therapy. Therefore many of them also use alternative therapies, but we still miss data on the use of alternative therapies in anorectal disorders. Therefore we looked for the use of alternative therapies in patients submitted to anorectal manometry.

MATERIAL AND METHODS

60 consecutive patients submitted to anorectal manometry were questioned about the use of alternative therapy by a specially developed structured questionnaire. All of them accepted to answer the questionnaire after careful instruction. The questions were administered by a qualified staff and filled before the investigation.

RESULTS

The indication for anorectal manometry was: incontinence 18 cases (20%), constipation 33 cases (55%), anorectal pain 9 cases (15%). 44 out of 60 (73%) patients admitted to have used one or more alternative therapies, usually together with the observance of medical dietary or pharmacological prescriptions. These were: homeopathy 10 (17%), herbal therapy 36 (60%), acupuncture 1 (0.02%), bioenergy resonance 11 (18%). Users were mainly females with a low level of education. The use of alternative therapy was similar in all three subgroups of patients.

CONCLUSION

These data emphasizes the importance of the use of alternative therapies in patients with anorectal disorders submitted to anorectal manometry.

Patient-identified quality indicators for colonoscopy services

BACKGROUND

Current quality improvement tools for endoscopy services, such as the Global Rating Scale (GRS), emphasize the need for patient-centred care. However, there are no studies that have investigated patient expectations and/or perceptions of quality indicators in endoscopy services.

OBJECTIVES

To identify quality indicators for colonoscopy services from the patient perspective; to rate indicators of importance; to determine factors that influence indicator ratings; and to compare the identified indicators with those of the GRS.

METHODS

A two-phase mixed methods study was undertaken in Montreal (Quebec), Calgary (Alberta) and Hamilton (Ontario) among patients ≥18 years of age who spoke and read English or French. In phase 1, focus group participants identified quality indicators that were then used to construct a survey questionnaire. In phase 2, survey questionnaires, which were completed immediately after colonoscopy, prompted respondents to rate the 20 focus group-derived indicators according to their level of importance (low, medium, high) and to list up to nine additional items. Multiple logistic regression analysis was used to determine the factors that influenced focus group-derived indicator ratings. Patient-identified indicators were compared with those used in the GRS to identify novel indicators.

RESULTS

Three quality indicator themes were identified by 66 participants in 12 focus groups: communication, comfort and service environment. Of the 828 surveys distributed, 402 (48.6%) were returned and 65% of focus group-derived indicators were rated highly important by at least 55% of survey respondents. Indicator ratings differed according to age, sex, site and perceived colorectal cancer risk. Of the 29 patient-identified indicators, 17 (58.6%) were novel.

CONCLUSIONS

Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.

Quality assurance for gastrointestinal endoscopy

PURPOSE OF REVIEW

This review concerns quality assurance for gastrointestinal endoscopic procedures, especially colonoscopy and will emphasize research and guidelines published since January 2011. Important articles from previous years have been included for background.

RECENT FINDINGS

Critical lapses in endoscope processing and administration of intravenous sedation alerted us to the infection risk of endoscopy. Increases in cost of colonoscopy, evidence for overuse and studies demonstrating missed cancers have led some to question the value of endoscopy. Despite these setbacks, the National Polyp Study (NPS) consortium published their long-term follow-up of the original NPS patients and confirmed that colonoscopy with polyp removal can reduce the risk of colorectal cancer for an extended period. In this article, we will focus on ways to improve the value of outpatient colonoscopy.

SUMMARY

The United States national quality improvement agenda recently became organized into a more coordinated effort spearheaded by several public and private entities. They comprise the infrastructure by which performance measures are developed and implemented as accountability standards. Understanding wherein a gastroenterology (GI) practice fits into this infrastructure and learning ways we can improve our endoscopic practice is important for physicians who provide this vital service to patients. This article will provide a roadmap for developing a quality assurance program for endoscopic practice.